All inspections: South East Coast Ambulance Service NHS Foundation Trust

South East Coast Ambulance Service NHS Foundation Trust (SECAmb) provides services to Brighton & Hove, East Sussex, West Sussex, Kent, Surrey, and North East Hampshire. This diverse geographical area includes densely populated urban areas, sparsely populated rural areas and some of the busiest stretches of motorway in the country.

The trust employs over 4,500 staff working across 110 sites in Kent, Surrey and Sussex. Almost 90% of the workforce is made up of operational staff who care for patients either face to face, or over the phone at the emergency dispatch centre where 999 calls are received.

Patients range from the critically ill and injured who need specialist treatment, to those with minor healthcare needs who can be treated at home or in the community.

As well as a 999 service, the trust also provides the NHS 111 service across Sussex, Kent and Medway.

Since June 2011, the responsibility for the delivery of the emergency preparedness policy of NHS ambulance services in England has been delegated to the National Ambulance Resilience Unit (NARU).

From April 2013, all NHS organizations have been required to contribute to coordinated planning for both emergency preparedness and service resilience through their local health resilience partnerships (LHRPs).

The SECAmb has a crucial role in the national arrangements for emergency preparedness, resilience and response (EPRR). The service is part of the civil contingency planning for both the NHS and the wider emergency preparedness network and must be able to demonstrate it can effectively manage the impact and aftermath of a major incident.

How we carried out the inspection

At our last inspection in February 2022, the overall rating of trust well-led went down. We rated it as inadequate and the chief inspector of hospitals recommended to NHS England and NHS Improvement (NHSEI) that SECAmb be placed in the Recovery Support Programme. During the previous inspection we identified further checks we needed to be carried out. Therefore, we suspended the trust's overall rating. During this current inspection we reviewed the trust's overall rating following inspection of the two remaining core services.

We inspected emergency and urgent care services. We visited the make ready centres at Paddock Wood and Ashford. We also visited three NHS hospital emergency departments to observe care and talk to staff. We spoke to over 50 members of staff which included; paramedics, emergency care support workers, student paramedics, operational managers, operational team leaders, a driving training manager, pharmacy support staff, associate ambulance practitioners, trainee associate ambulance practitioners and a practice development lead. We spoke to three patients and one relative and reviewed a variety of data.

We carried out a comprehensive inspection of the Resilience core service. Resilience services were located at Gatwick and Ashford Made Ready Centres. We inspected both locations on two occasions between the 22 July and the 2 August 2022. During the inspection process, we spoke with the director of the service, two operations managers, three operational team leaders and 10 Hazardous Area Response Team (HART) operatives across both sites.

You can find information about how we carry out our inspections and previous ratings for this service on our website:
https://www.cqc.org.uk/what-we-do/ how-we-do-our-job/what-we-do-inspection.

We conducted this comprehensive short notice unannounced inspection of the emergency and urgent care and resilience core services. We inspected emergency and urgent care on 26 July 2022 and resilience on 26 July 2022 and 02 August 2022. We rated both emergency and urgent care and resilience as requires improvement overall.

What we found

Emergency and urgent care

Our rating of this service went down. We rated the service as requires improvement because:

The service provided mandatory training in key skills to all staff but not everyone had completed it. The service did not share learning from incidents with staff and staff often did not get feedback from incidents they had reported.
There was a lack of training for medicines management, specifically for patient group directions.
The service did not always support staff to develop their skills. Managers and staff told us that any additional training courses had to be self-funded and completed in their own time.
Managers did not routinely appraise staff’s work performance or hold supervision meetings with them to provide
support and development. Managers did not always make sure staff were competent.
Staff did not receive training in patient restraint techniques. The trust did not have oversight regarding how often restraint was used and whether it was done safely. The trust did not have a restraint policy.
The service did not always make it easy for people to give feedback. People could not always access the service when they needed it and patients often experienced delays in receiving treatment.
There were additional risks for patients from handover delays for ambulance crews at emergency departments which were unable to take patients due to their lack of capacity.
The NHS contractual response times for ambulances to attend patients were not being met and some were exceptionally long, ambulances were waiting at emergency departments due to the increased demands and capacity pressures in hospitals and other parts of the health and social care system.
Leaders did not have the capacity or support to run the service well. Not all staff felt respected, supported and valued.
Staff felt there was an overall lack of a strategy and vision for the service. Staff felt there was a lack of urgency and ownership of responsibilities within the service.
There was not an effective communications system to ensure staff had read and understood key information.
Staff were not clear on the roles and responsibilities of managers. For concerns requiring action from senior leaders in the organisation there were often delays in getting a response impacting on the ability of local leaders to deal with issues and concerns at a local level in a timely way.
Managers did not have enough time to dedicate to the welfare, professional development and training of the staff they managed. There was conflicting and changing demands placed on all levels of managers from the senior leadership team and there was a lack of cohesive working.
There was evidence of staff under such pressure that it was having a detrimental effect on both their mental and physical wellbeing. Most of the staff described feeling exhausted and burnt-out by the job with the current pressures.
Not all staff felt that staff welfare was given sufficient priority.

However:

The service controlled infection risk well. Staff assessed risks to patients and acted on them. Staff generally managed medicines well.
Staff kept detailed records of patients’ care and treatment. Records were clear, stored securely and easily available to all staff providing care.
Staff provided care and treatment based on national guidance and evidence-based practice. The service monitored the effectiveness of care and treatment.
Staff treated patients with compassion and kindness, they provided emotional support to patients, families and carers to minimise their distress. Staff supported and involved patients, families and carers to understand their
condition and make decisions about their care and treatment.
Staff worked well together for the benefit of patients, for example with staff in emergency departments. Despite the immense pressure faced every day, staff were kind, compassionate and supportive to patients.

Resilience

Our rating of this service went down. We rated it as requires improvement because:

Not all staff had completed safeguarding training at a level appropriate to their role.
The service were not always able to demonstrate how they measured IPC effectiveness and infection control risk.
The service did not always keep equipment and vehicles in line with their documented policies and processes.
The service had limited learning from safety incidents and incident reporting was low for the service.
Staff were not always clear about information communicated through the meeting structure of the service.
Some staff did not always feel respected, supported and valued.
Managers showed limited strategies and systems to improve the service using quality improvement techniques.

However:

Staff had training in key skills and understood how to protect patients from abuse. Staff assessed risks to patients, acted on them and kept good care records. The service managed medicines well.
Staff provided good care and treatment to patients and gave them pain relief when they needed it. Managers checked the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients and had access to good information. Staff showed knowledge of consent and the considerations of patients who lacked capacity to make decisions. Staff worked with other services to ensure best outcomes; key services were available seven days a week.
Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers. Staff engaged well with patients and were focused on the needs of patients receiving care.
The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
Leaders supported staff to develop their skills. This included highly specialised training which was monitored effectively.

Our inspection team

Emergency and urgent care

The team that carried out the inspection comprised an inspection manager, lead inspector, two other CQC inspectors and two specialist advisors. The inspection team was overseen by Carolyn Jenkinson, Head of Hospital Inspection.

Resilience

The team that carried out the inspection comprised a lead inspector, one other CQC inspector and one specialist advisors. The additional visit had a team of two CQC inspection managers and two CQC inspectors. The inspection team
was overseen by Carolyn Jenkinson, Head of Hospital Inspection.

Our reports

We plan our next inspections based on everything we know about services, including whether they appear to be getting better or worse. Each report explains the reason for the inspection.

This report describes our judgement of the quality of care provided by this trust. We base it on a combination of what we found when we inspected and other information available to us. It includes information given to us from staff at the trust, people who use the service, the public and other organisations.

Overall Summary

Our overall rating of well-led went down. We rated it as inadequate and the chief inspector of hospitals has recommended to NHS England and NHS Improvement (NHSEI) that it be placed in the Recovery Support Programme.

A trust may be placed in the Recovery Support Programme for quality reasons when:

It is rated ‘inadequate’ in the well-led key question (because there are concerns that the organisation’s leadership is unable to make sufficient improvements in a reasonable timeframe without extra support)
A trust placed in the Recovery Support Programme receives intensive support to help it improve. It must produce an improvement plan setting out what it will do to bring services up to the required standard.

During this inspection we identified further checks we needed to carry out. In the meantime, we have suspended the trust's overall rating. This will be reviewed once the checks are completed.

South East Coast Ambulance Service NHS Foundation Trust (SECAmb) was established on 1 July 2006. On 1 March 2011 SECAmb became a Foundation Trust.

The trust covers 3,600 square miles which includes densely populated urban areas, sparsely populated rural areas and some of the busiest stretches of motorway in the country. It serves a population of over 5 million people.

The trust employs over 4,500 staff working across 110 sites in Kent, Surrey and Sussex. Almost 90 per cent of the workforce is made up of operational staff – those caring for patients either face to face, or over the phone at the trust emergency dispatch centre where the trust receive 999 calls.

Patients range from the critically ill and injured who need specialist treatment, to those with minor healthcare needs who can be treated at home or in the community.

As well as a 999 service, the trust also provides the NHS 111 service across Kent and Sussex. The trust also has a Hazardous Area Response Team (HART) which was not inspected at this time.

During March 2022, we undertook a focused inspection of the Emergency and Urgent Care services as part of a pilot approach of the urgent and emergency care pathway across Kent and Medway. This was to assess how patient risks were being managed across health and social care services during increased and extreme capacity pressures. A short notice period was given prior to the inspection. We also undertook an inspection of the Emergency Operations Centre and 111 service using our comprehensive inspection framework and due to concerns about leadership quality and culture in the organisation we inspected the well-led key question for the trust. We did not inspect the resilience core service (HART) on this occasion.

Following this inspection we have suspended the overall ratings for the trust while we carry out further checks on all the provider's locations.

In 111 the overall rating stayed the same. We rated safe, effective, caring, and well-led as good. We rated responsive as requires improvement.
In Emergency Operations Centre the overall rating went down. We rated the caring domain as good however, we rated safe, effective, responsive and well-led as requires improvement.
The Emergency Urgent Care service was unrated due to being part of a system review to ensure consistency with other ambulance trusts.
The ratings for the well-led inspection went down.
In rating the trust, we took into account the current ratings of the other core services not inspected this time.

What we found.

111 Service

Our ratings for the service stayed the same. We rated it as Good.

The service had good systems to manage risk so that safety incidents were less likely to happen. When they did happen, the service learned from them and improved their processes.
The service routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
Staff involved and treated people with compassion, kindness, dignity and respect.
Patients were able to access care and treatment from an integrated service with specialisms to meet their needs.
There was a strong focus on continuous learning and improvement at all levels of the organisation.

However:

The trust was not meeting the key performance indicators on clinical call back times, call abandonment rates and call response times.
The trust did not always support the workforce in order to reduce the pressure and improve staff morale.

Emergency Urgent Care. Due to the focused nature of the inspection, we did not rate the core service. The previous rating of outstanding remains.

The significant rise in numbers of callers to 999, in excess of what the trust was commissioned for combined with crews being delayed at emergency departments meant the trust was unable to reach all patients in a timely way. As a result, the service was not meeting any NHS constitutional ambulance response times, which was a similar picture across the ambulance services nationally.
The exceptional demand was increasing, and this was becoming unsustainable for staff across the service.
There were additional risks for patients from handover delays for ambulance crews at emergency departments which were unable to take patients due to their lack of capacity.
Due to delays in response times as a result of increased demand, there were risks of harm to patients who were in the community.
The service planned care to meet the needs of local people, however it didn’t always take into account patients’ individual needs and did not provide people with information on how to give feedback.
The trust did not always support staff to develop their skills. Managers and staff told us that any additional training courses had to be self-funded and completed in their own time.
A high proportion of staff had not received an appraisal.
Not all staff felt connected to other teams and sites within their service and to the organisation as a whole.
Learning from low level harm and near miss incidents was not embedded and staff often did not get feedback from incidents they had reported.
Leaders were not always aware of the risks in their service or themes and trends in patients’ complaints.
There was a lack of a clear strategy and consistent approach in the management of ambulance response categories 3 and 4.
Staff felt there was an overall lack of a strategy and vision for the organisation.

However:

Staff worked well together for the benefit of patients and focused on the needs of patients receiving care.
Local leaders ran services well using reliable information systems.
The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records.
Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs and helped them understand their conditions. They provided emotional support to patients, families and carers.
There had been some excellent multidisciplinary working and mutual aid to and from the service. For example, an ambulance staffed by a paramedic and police officer to support patients experiencing severe mental ill health.
Despite the immense pressure faced every day, staff were kind, compassionate and supportive.

Emergency Operation Centre

Our rating for the service went down. We rated the Emergency Operations Centre core service as Requires Improvement.

The service did not always have enough staff to care for patients and keep them safe.
There was an expectation on staff to work overtime even though they were exhausted.
Staff were not up to date with mandatory training and training in key skills. Staff did not receive adequate training on patients who had mental health needs and felt this was a risk to the safety of their service.
The service did not manage safety incidents well. Incidents were often not investigated in a timely fashion and learning from incidents was not consistently shared with all staff.
The service did not ensure all staff had an appraisal and appraisal rates for the service were poor.
Staff understood how to protect patients from abuse, however safeguarding training compliance was worse than the trust target.
People could not always access the service when they needed it. Since the rise in demand and strain on response times, the service was no longer able to always meet the needs of patients.
People who did not speak English could sometimes not access the service in a timely way.
Leadership at a local level was good. However, staff did not feel visible or appreciated by senior leadership.
Not all staff felt respected, supported and valued. Not all staff felt they could raise concerns without fear, even though there was a freedom to speak up guardian in post that staff were aware of.
Leaders did not support staff to develop their skills. Opportunities for development were limited and staff were expected to do any continuous professional development in their own time.

However:

Staff assessed risks to patients, acted on them and kept good care records.
Staff worked well together for the benefit of patients.
Staff treated patients with compassion and kindness, even when they were under a vast amount of pressure themselves. They were focused on the needs of patients requiring care.
There were processes in place to ensure the service could continue in the event of a business continuity incident or other events that could stop the service running effectively.
Staff knew about the values of the service.

Trust wide

Leaders had the experience, capacity and capability to lead effectively. However, the current leadership style and relationships in the executive team were not operating as effectively or cohesively as it should.
Communication at all levels was poor. Staff provided us with many examples of this during the inspection.
Leaders were out of touch with what was happening on the front line, and they were not always aware of the challenges in the service.
Leaders were not visible and did not act in line with the trust’s own values when staff raised concerns.
Not all staff felt respected, supported and valued. Staff were focused on the needs of patients receiving care.
Not all staff felt they could raise concerns without fear of reprisal.
Staff reported low levels of satisfaction and high levels of stress and work overload.
We found high levels of bullying and harassment, inappropriate sexualised behaviour and a high number of open grievances.
There was insufficient resource allocated to FTSUG, safeguarding and medicine management team.
The governance systems at the trust were not operating in a way that protected patients or staff from the risk of harm.
Key reports to board were not prepared in a standardised way.
Risk, issues and poor performance were not always dealt with appropriately or quickly enough.
We found a back-log of 1500 incidents on the incident reporting system.

However:

We found good collaborative working between the FTSUG and union representatives.
The trust had an award-winning wellbeing hub that provided invaluable cost-effective support to staff.
The trust was making progress with the equality, diversity and inclusion agenda.
The trust was well on its way to becoming a digitally mature organisation. There was record investment in IT infrastructure to future proof the organisation
The trust had used the pandemic to improve its visibility, influence and focus in the local system. We saw improved levels of engagement with other key stakeholders. The trust had become a more outward facing organisation.
The strategy director work programme was having a positive impact on the trust’s ability to translate data into service planning, delivery and organisational strategy.

How we carried out the inspection

We looked at information such as staffing number and rotas, staff training, clinical stack management.
We looked at medicines management, checked equipment, medical devices and consumables.
We reviewed information provided by the service following the inspection.

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

Most patients praised the care, treatment and support they received from the service. However, we also saw concerns about the excessive ambulance waiting times and staff attitude.

Our rating of the trust improved. We rated it as good because:

Safe, effective, caring, responsive and well led were good.
Emergency and urgent care services were rated as outstanding overall. The service was rated as good for safe, effective, responsive and outstanding for caring and well led. This was an improvement from our last inspection.
The emergency operations centre was rated as good overall. It was rated good for safe, effective, caring, responsive and outstanding for well led. This was an improvement from our last inspection.
The 111 service was rated as good overall. It was rated as good for safe, caring, responsive, well led and requires improvement for effective. This was the same as the last inspection.
In rating the trust, we took into account the current ratings of the service not inspected this time.

Our rating of this service improved. We rated it as outstanding because:

The service was good in safe, effective, responsive, well led and was outstanding in caring. Four out of five domains had improved since our last inspection.
Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
Staff provided good care and treatment and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients and had access to good information. Key services were available seven days a week.
Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work.Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

Our rating of this service improved. We rated it as good because:

The service improved to good in safe, effective, responsive and well led, remained good for caring.

The service had implemented a demand and capacity review model to improve and increase staffing within the centre. We found the service had actively looked at ways to increase staff and attract the right people to apply for specific centre roles.

The service provided care and treatment based on national guidance and evidence-based practice. The trust continuously reviewed policies to reflect national guidance. We found both centre site staff were aware of current policies and there had been an improvement in how staff access and record that they have read updated or new guidance.

The computer aided dispatch system was introduced in July 2017 prior to our previous inspection. Following recommendations given during our last inspection the trust had improved the dispatch system to provide better information in regard to the patients age, gender and condition. Clinicians told us that this new update was working well to triage and prioritise patients within the clinical stack.

A clinical safety navigator (CSN) had been newly introduced during our last inspection of the service. The CSN role was to have full oversight of the clinical stack, prioritise and triage patients to make sure all patients received a clinical review or a welfare call within targeted timeframes. During our last inspection we found staff did not understand the role of the CSN and there were no clear guidelines for the role in place. However, we found during this inspection, the trust had a clear policy in place for the role and responsibility of the CSN. We found clinicians fully understood the role of the CSN and recognised this was an important role in managing the clinical stack under times when there were high pressures and long waits within the service.

The Manchester Triage system was fully embedded and used by registered clinical staff. Clinicians recognised the benefits of the system as it had increased clinical hours on average of 127 per week since January 2019. Manchester triage enabled clinicians to assign a clinical priority to patients, based on presenting signs and symptoms, without assuming the underlying condition.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. There was a strong, visible person-centered culture. Staff were highly motivated and inspired to offer care that was kind and promoted people’s dignity.

Staff provided emotional support to patients, families and carers to minimise their distress. Staff were always calm when patients or callers were anxious. We observed team leaders supporting staff during difficult calls with patients.
We found that since our previous inspection the trust had put a number of initiatives in place to manage the risks to ‘no send’ patients during times when surge management was active. The new surge management plan had been reviewed to improve how category three and four calls were managed more effectively.
During our last inspection, we found that there was not a clear oversight of long lying patients or elderly fallers. The update to the dispatch system gave better oversight to the age of the faller and a clearer oversight of where the patient was, the environment around them and if they were supported due to the free field text on the dispatch system. Clinicians told us that this enabled them to triage a patient and to prioritise the patient to a category two.
The time taken to review complaints had improved significantly from the previous year with complaints taking on average 17.1 days to review compared to 33 days the previously. This met the trust target of 25 days.
The leaders within the centre service showed they had integrity, were knowledgeable, experienced and well respected by all staff we spoke with during our inspection. There were comprehensive and successful leadership strategies in place to ensure delivery and to develop the desired culture. Staff told us they knew who to approach for guidance and advice and they described the service leaders and senior staff as approachable.
We found leaders had a clear oversight of the centre risk register and potential risks to service delivery and safety. During our last inspection, leaders were unclear as to the extent of the poor quality of the voice recordings. However, we found the leaders were clear that the voice recordings were no longer a risk. There was clear monitoring of voice recordings and a new telephony system was in place which recorded calls clearly.

However:

The service did not have enough clinicians in post to meet the demands of the service. Staff felt there were not enough clinicians to manage the demand of the service within the centre. We observed clinical staff rotas which showed there was a lack of clinicians and the senior clinical operations manager (SCOM) recognised the concerns also.
We reviewed clinical audits which showed us clinical welfare calls were not completed within the specified timeframe. This was likely to be due to lack of clinicians and high demand on the service.
Staff told us that the service was often in surge management. We were told there was mostly large numbers of patients waiting within the clinical stack and we found there were not enough clinicians at times to meet the demand. This raised concerns that the service was unable to effectively manage the demand of the service and was a risk to patients. For example, the risk of deterioration to health for category three patients such as elderly fallers.

In both the emergency operations centre (EOC) and emergency and urgent care (EUC) we rated safe, effective, responsive and well-led as requires improvement and rated well-led in resilience as requires improvement.
We rated safe, effective and responsive in the trust’s resilience core service as good. We rated caring as good across all three core services.
In rating the trust, we took into account the current ratings of the 111 service, which was not inspected this time.
We rated well-led for the trust, overall, as requires improvement.

Our rating of this service improved. We rated it as requires improvement because:

We found the trust made significant improvements since our last inspection. The commitment of the EUC staff and senior leadership team to improve was notable. We recognised a positive shift in organisational culture, and many new systems and processes having an improved and measurable impact on the service. However, at the time of the inspection many of these changes were still very new and required additional time to become embedded practice.
While we saw improvements to the way in which equipment was managed and maintained we identified one member of staff using personal issue equipment with no assurance that these items were in good working order. We also received three contacts from staff making us aware of their concerns with the accuracy of the asset register. We made the trust aware of the concerns we received as the inspection process was unable to prove or disprove the concerns.
Manual handling equipment was not consistently used, resulting in observed unsafe manual handling practices. Comprehensive risk assessments were not always carried out as clinical observations were not consistently undertaken. Not all patients, where applicable, had their blood glucose level checked in accord with policy and a second set of clinical observations was not consistently carried out even when patients had been administered morphine.
People’s individual care records, including clinical data, were not always written and managed in a way that kept people safe as there were entries that were not sufficiently completed. We acknowledge the trust was reviewing the patient clinical record to make improvements and we saw that records were routinely audited by team leaders.
Staff did not always report delays where patients who had fallen at home may be waiting for several hours and staff did not report an incident relating to a lack of consumable equipment at the time of our inspection.
While some staff told us they were encouraged and given opportunities to develop, others told us they believed that internal processes made it difficult for other staff to progress. Some paramedic practitioners told us that there were improved opportunities in hospitals and primary care but that the trust needed to take more action to support development opportunities internally.
There were significant delays in handing over of patients at emergency departments, which meant ambulance staff needed to stay with their patients to deliver care and support them until they were handed over to hospital staff, which in turn reduced the capacity of front line staff to respond to emergencies.
Although ambulance crews had access to specialist ambulances that could be used to transport bariatric patients, these were not always available. One crew described being refused the use of the specialist ambulance, which staff felt was unnecessarily undignified for the patient.
We identified inconsistencies in station managers and Operational Team Leader’s insight into their own stations risks and the Emergency and Urgent Care core service as a whole. Managers were not always aware of what was on the trust risk register. This meant that local managers were not always aware of the risks in the service which meant that action could not be taken to reduce risk and improve patient care, staff and the wider organisation.
We were made aware of an inconsistent approach to the delivery of regular staff meetings across the three counties. Some stations could demonstrate regular staff meetings with a set agenda while others didn’t. This meant that some staff did not have a forum to raise concerns or comments, or catch up on organisational learning and key communications
At our last inspection staff told us they were not able to have regular meal breaks. Whilst we found this had improved, we were still aware that some crews were unable to have a meal break and experienced shift over runs.

However:

One of the concerns from the last inspection related to a culture of bullying and harassment. The trust had taken steps to address this. We received positive feedback from staff who recognised a change in culture. However, others told us they were still affected by it.
The trust had improved its systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. However, these processes were still being developed and not fully embedded in practice.
It was clear there was a significant improvement required to help staff understand the governance systems and processes. We received mixed feedback which indicated that governance processes and the importance of such processes, was not widely understood by staff.
We saw better staff training in safety systems, processes and practices. There were systems and processes in place to protect people from abuse and harm. Staff understood their responsibilities and the process to follow in the event of any safeguarding concerns and we found that overall compliance with mandatory training had increased from 85% at our last inspection to 93.2%.
There were good standards of cleanliness and hygiene were maintained throughout the vehicle fleet and we found reliable systems in place to prevent and protect people from infection. The trust had implemented an infection prevention improvement plan since the last inspection and staff demonstrated good infection control practices.
Staffing levels and crew skill mixes were routinely planned and reviewed. Information needed to deliver safe care and treatment was available to relevant staff in a timely and accessible way with the introduction of electronic mobile devices which contained patient information as well as trust protocols and procedures.
Medicines were managed safely and securely. The trust made sure that patients received their medicines as intended and that this was recorded appropriately. An automated medicines management system had been implemented in larger ambulance stations to improve the safety of medicines.
Lessons were learned and improvements made when things went wrong. Staff reported a learning focus around incident reporting and there were effective arrangements to respond to relevant external safety alerts and when things went wrong. Staff understood their responsibilities to raise concerns, to record and report safety incidents, concerns and near misses.
People's physical, mental health and social needs were holistically assessed, and their care, treatment and support was delivered in line with legislation, standards and evidence-based guidance. The trust had care pathways and protocols in place that incorporated guidance from the National Institute for Health and Care Excellence and other expert professional bodies. Staff demonstrated familiarity with the guidance and we observed this being followed.
Patient outcomes and comparators varied, but were broadly similar to other trusts and showed improvements since our last inspection. The service had enhanced clinical and other audits through increased resourcing of front line leadership.
The learning needs of staff were identified and there was appropriate training and support available to meet those needs. There was protected time for training and experienced staff available to provide clinical supervision and support in decision making.
Care was delivered and reviewed in a coordinated way between different teams, services and organisations. Staff within the trust worked collaboratively with other services to develop and improve care pathways for patients. This included working collaboratively with hospital staff to reduce the waiting times for patients in accident and emergency departments and ensure that patients who did not need to be conveyed to hospital had the appropriate support.
Patients who needed extra support were identified. The trust had a comprehensive approach to supporting frequent callers that included signposting them to other services and liaising directly with primary care services to ensure that appropriate support was available in the community.
Staff understood the relevant consent and decision-making requirements of legislation and guidance, including the Mental Capacity Act 2005. Mental capacity assessments were consistently carried out and staff had relevant guidance and support available for this.
Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them with dignity and respect. Staff involved patients and those close to them in decisions about their care and treatment. Patients confirmed their care had been discussed with them; they were able to ask questions and felt included in the decisions about their care. All staff we spoke with were passionate about their roles and were dedicated to making sure patients received the best patient-centred care possible.
The service treated complaints seriously, investigated them and learned lessons from the results, which were shared with staff.
The trust planned and provided services in a way that met the needs of local people. They developed ways to ensure the service was as responsive as possible given the demands on the service. The trust worked well with commissioners and local stakeholders to meet the needs of the local populations. The service also took account of patient’s individual needs.
There were processes in place to ensure the needs of people with a mental health illness were met. The trust employed mental health nurses to provide support and guidance to frontline crew.
The trust collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards.
The trust had improved the way it engaged with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.

At our previous inspection we rated this service as requires improvement.

Our rating of this service stayed the same. We rated it as requires improvement because:

We found a lack of systems and processes to effectively identify and manage the level and severity of risk for calls waiting in the stack. This was despite the introduction of a clinical navigator role. Following our inspection, the trust had updated the clinical safety navigator guidelines and shared with the clinical teams. A working group had been established to provide a bi weekly update to provide intensive support to clinicians and the ‘clinical stack’ to reduce waiting times for callers.
Patients classified as category three (elderly fallers and long lying patients) were at high risk of deterioration as a result of experiencing long delays. Staff did not report this through the incident reporting system. However, this was raised with the trust who took immediate action to audit and improve incident reporting as a result.
Calls could not be audited in line with the NHS pathways contract. We identified concerns with the call recording system which resulted in poor audit quality, calls merged together, and partially recorded calls. We raised this with the trust who put systems and processes in place to audit the frequently of these calls as well as a paper record of all conjoined calls to help future retrieval.

Sickness rates within the emergency operation centre (EOC) exceeded trust target despite the trust having raised sickness rate targets since our last inspection. The trust had introduced a human resources advisor to provide support to the EOC staff to reduced absence. However, it was too early to comment on the impact of the initiative.
The national Ambulance Response Programme introduced by the trust in November 2017, measured the time it took from receiving a 999 call to a vehicle arriving at a patient’s location. The trusts performance from December 2017 to May 2018, time in which 50% of calls were answered were 29.8 seconds longer in December, and 2.6 seconds longer for the remaining five months than the England average.
The trust consistently performed worse than the England average between December 2017 to May 2018, when looking at the data of time within which 95% of calls were answered. The trust were 251 seconds longer than the England average in December and 62.7 seconds longer than the England average in May. However, under the new metrics the trust showed a steady improvement.
Data measured showed us the proportion of patients re-contacting 999 within 24 hours of original emergency call closed with telephone advice, had a consistently higher proportion of patients than the England average from June 2017 to November 2017. A decline in trust performance, from 6.2% in June 2017, compared to the England average of 6.4%, to 13.9% in November 2017 compared to the England average of 10.7% was shown. This could mean patients receiving initial telephone advice were either unhappy with the advice given or their symptoms or complaint had worsened.
Mental Capacity Act training compliance was reported as 81.4%, which was less than the trust target of 95%. However, we found staff were aware of the processes to ensure people with mental health issues were well supported. Call takers followed NHS pathways and clinicians to assess for mental health needs or risk behaviours. Clinicians completed capacity assessments and ambulances were sent to patients assessed as lacking capacity.
People could not always access the service when needed. A surge management policy was used within the EOC when demand for the service outweighed available resource capacity. This meant patients who were not classed as a category one or two were not sent ambulance assistance (no-send) but directed to other services or placed within the clinical stack for a clinician review.
Clinicians felt that the computer aided dispatch system did not provide enough information to be able to determine patients’ priority or risk severity. This contributed to the long delays we observed in patients receiving a clinical review. Since our inspection a free text field had been added allowing clinicians to record additional clinical details and priority indicators.
Staff lacked insight into when ‘no-send’ calls should be reviewed when the surge management policy was activated. Staff were unable to determine if a patient’s condition had deteriorated and escalated to category one or two. However, following our inspection the trust had amended the surge management policy to include defined clinical review timeframes.
During the inspection we identified nine out of 73 patients received the required number of welfare calls in line with trust policy. EOC data showed us that during that time the patient should have received 10 welfare calls. We found no welfare calls were made despite the patients recorded risk score of eight. Data showed the longest wait for a response was six hours and eight minutes.
EOC received 593 complaints in 2017/2018 and were worse than the previous year where 432 complaints were recorded. The most common complaint related to ambulance response times. The trust received 415 complaints received this year, compared to 204 the previous year.
We found a lack of insight from senior leaders into the quality of the 999 call voice recordings. Senior managers were unclear as to whether recorded calls could be quickly retrieved should there be an urgent need to get details from the call recording quickly. However, following the inspection we found the trust had been monitoring call recordings far greater than five other ambulance trusts. The trust told us there had been no incidence of recorded calls where information could not be immediately retrievable. There was clear executive oversight with call recordings being listed on the standard agenda on the executive management board.
Our last inspection identified concerns with a culture of bullying and harassment. At this inspection staff told us that this had mostly improved because there was better support to raise concerns about poor behaviour. However, some staff told us there were still members of the team whom made it difficult for others. They told us about concerns about individuals moving to other parts of the organisation which did not deal directly with poor behaviour.
Call takers and dispatchers felt well supported and spoke highly of the senior team leaders. However, we observed different cultures between the two EOC sites. Staff based at Coxheath felt less valued than their colleagues at Crawley.

However:

Data showed 98% of registered healthcare professionals had completed safeguarding level three adult and children training. This was a significant improvement on our previous inspection findings.
A joint working project was in place between the trust and Kent police. Staff reported this was working well and hoped would continue. The project was in operation on Friday and Saturday nights and was to jointly respond to any incidences which involved alcohol related injuries, domestic disputes and mental health incidents
A mental health ‘street triage’ service was starting to be trialled within Coxheath EOC during our last inspection. Recent data showed a reduction in the proportion of patients attending accident and emergency departments for a mental health condition from an average of 53% to 7%.
Patients were treated with dignity and compassion. We observed staff give reassurance to callers and stayed calm during difficult and distressing situations. During cardiac arrests we observed call takers staying on the telephone line to offer support until an ambulance crew arrived.
Staff provided emotional support to patients to minimise their distress. We listened to call takers providing callers and patients with reassurance, speaking calmly and clearly to emotionally distressed patients.
The trust had not completed a patient survey over the last 12 months, however the trust website had a ‘contact us’ tab and a ‘we’d like to know what you think’ leaflet. Notice boards were seen in both EOC sites with patient feedback and positive comments displayed. Positive comments such as ‘we are sincerely grateful to you all’ and ‘they were very thorough and their passion and dedication really shone through’
The trust amended the surge management policy immediately after the inspection. The update included the introduction of formal timeframes for reviewing the ‘no send’ calls. To gain further insight into ‘no send’ calls the trust will complete an audit each month to be reviewed by the surge management review group.
‘Hear and treat’ patients had increased from 64,000 to 69,000 each month. The ‘hear and treat’ service did not require ambulance transportation to accident and emergency.
Dementia training was provided to all staff. Any patients identified as living with dementia had an ambulance automatically dispatched to allow crews to carry out a full, face-to-face assessment and respond to the patient’s individual needs.
Most staff told us they felt valued, listened to and respected and there had been a significant change in leadership style since our previous inspections. We saw positive examples of leadership from the EOC managers at both EOC locations. Staff told us team leaders would support them during difficult or concerning calls and arrange support from the clinician if necessary.
There was a trust vision and strategy that was developed collaboratively with staff. New values were developed to support and drive a change in organisation culture.
The systems and processes to report, investigate and learn from incidents had significantly improved. Staff felt actively encouraged to be open, candid and learn from incidents. Reporting of near misses and no harm had increased by 40% since our previous inspection, identifying that staff were compliant in reporting incidents. However, we identified concerns for patients who experienced excessive delays, as this was not reported formally as an incident.

We rated it as good because:

Much progress had been made since the last CQC inspection to ensure the service met national standards and SECamb was able to provide an effective and timely response to planned events and catastrophic incidents.
The number of paramedics in the HART had increased, ‘all technicians had undergone the required training and qualified as paramedics’ and this was in line with the National Ambulance Resilience Unit (NARU) guidance. There was a dedicated and skilled team of the Hazardous Area Response Team (HART) paramedics who cared strongly about the work they did.
Hazardous Area Response Team (HART) specific training was well attended, well managed and they were an accredited training centre for water rescue and rope rescue.
Security at the team sites was robust and staff had received up-to-date training in all safety systems, processes and practices.
Appraisal rates were higher than the trust’s benchmark and staff were positive about the training they had attended.
There was effective partnership working with organisations across Kent, Surrey and Sussex for major events along with multiagency training.
Staff were using evidence based practice and working to national guidance for HART/CBRN/Marauding Terrorist Fire Arms Attacks (MTFA).
Although we were unable to observe EPRR providing care, SECamb provided us with examples of positive feedback from patients/public about care delivered by EPRR staff.
Staff were positive about their immediate line and local managers but some still felt more could be done to improve communication and take action in response to feedback from staff.

However:

Safety concerns were not addressed quickly enough. Learning from significant events attended by EPRR staff was sometimes shared but learning was slow to disseminate and the trust was slow to act on responses from national incidents such as the Kerslake Report, Grenfell and their own operational exercises.
The trust business continuity plan was not aligned with other trust policies and plans. There was no collaboration across the trust to ensure that widespread organisational business continuity management was effective.
Response times were not monitored for Hazardous Area Response Team (HART) operations so the trust had no assurance that national targets were being met.
The leadership structure was confusing, staff felt demoralised by changes that had occurred and when asked struggled to explain the reporting lines.

South East Coast Ambulance Service NHS Foundation Trust (SECAmb) is part of the National Health Service (NHS). The trust came into being on 1 July 2006, with the merger of the former Kent Ambulance Service, Surrey Ambulance Service and Sussex Ambulance Service. On 1 March 2011 SECAmb became a Foundation Trust. The trust employs approximately 3,300 staff working across 110 sites in Kent, Surrey and Sussex. This area covers 3,600 square miles which includes densely populated urban areas, sparsely populated rural areas and some of the busiest stretches of motorway in the country. It has a population of over 4.5 million people. There are 12 acute trusts within this area and 22 Clinical Commissioning Groups (CCGs). The trust responds to 999 calls from the public and urgent calls from healthcare professional across Brighton and Hove, East Sussex, West Sussex, Kent and Medway, Surrey, and parts of North East Hampshire. It also provides NHS 111 services across the region.

The emergency operations centre (EOC) receives and triages 999 calls from members of the public and other emergency services. It provides advice and dispatches ambulances as appropriate. The EOC also provides assessment and treatment advice to callers who do not need an ambulance response, a service known as “hear and treat”. Callers receive advice on how to care for themselves, or staff direct them to other services that could be of assistance. The EOC also manages requests from health care professionals to convey people either between hospitals or from community services into hospital. The emergency operations centre received 1,016,944 emergency calls between April 2016 and March 2017. The total call volume had increased by 8.6% since 2014-15, when the trust received 929,822 calls. At the time of our inspection, the trust had three emergency operations centres at Coxheath, Banstead and Lewes. Staff at Lewes EOC were preparing to move into a new, purpose-built EOC in Crawley the week after our visit. The trust planned to move staff from Banstead EOC to the new facility in Crawley in September 2017.

The trust had previously been inspected in May 2016, when we rated the trust overall as inadequate. We had rated Emergency and Urgent Care (EUC) as inadequate and both the Emergency Operations Centre and Patient Transport Services were rated as requires improvement. As a result of the inspection, we issued a warning notice detailing the areas where the trust needed to make improvements. Following the inspection, the trust was placed in special measures.

We inspected this location as part of our planned comprehensive inspection programme to review progress against the requirements of the warning notice. Our inspection took place on 15 to 18 May 2017. We looked at two core services: emergency operations centres and emergency and urgent care, including resilience and the hazardous area response team. The trust no longer provides patient transport services across the region. The 111 service provided by the trust was inspected separately and the ratings are included here to contribute to the overall rating.

We rated South East Coast Ambulance Service NHS Foundation Trust as inadequate overall.

We rated the trust as inadequate for safety and the well led domain. We rated the trust as requires improvement for delivering an effective and responsive service. However, we rated the trust as good for caring.

Our key findings were as follows:

Safety:

The voice recording system had failed to consistently record all 999 calls since January 2017. This meant the trust failed to keep complete records for all patients to ensure safe care.

The trust did not protect service users against the risks associated with the inappropriate use and management of medicines. The trust did not always make appropriate arrangements for obtaining, storing, recording, dispensing, administering and disposing of medicines. We observed poor practice in medicine management, which did not meet best practice guidelines.

We found paper patient clinical records were not always fully or appropriately completed or stored securely, and the trust did not consistently audit these.

New systems to manage the risk of infection prevention and control had not been embedded. We observed varied standards of cleanliness. The national standards of infection control and environmental cleanliness were not being achieved or consistently audited across the trust. This meant the trust was not fully assured that patients and staff were protected from health care associated infections.

We found emergency equipment without asset numbers displayed and equipment that was overdue for servicing. This meant the trust could not be assured equipment had been adequately maintained and was safe to use.

There was a poor culture of reporting incidents, with some staff having never reported an incident and lacking knowledge of the trust’s incident reporting processes. There was limited sharing of learning from incidents. This meant the service might have missed opportunities to learn from incidents and improve patient safety. A backlog of incident forms meant the service did not always address safety concerns quickly enough.

There were times of insufficient staffing relating to clinicians in the EOC. At times, there were insufficient numbers of clinical supervisors at the individual sites to ensure patient safety.

Clinicians in the EOC and the EUC service did not all hold an appropriate level of safeguarding children training in line with national guidance. The trust had failed to address this risk, identified at our previous inspection in 2016, in a timely way.

The computer aided dispatch (CAD) system was unstable and this had resulted in two serious business continuity incidents between April 2016 and March 2017.

However:

A successful recruitment drive meant the EOC had more than the full complement of call handlers. Call handler staffing levels had improved since our last inspection, when there was a 22.2% call handler vacancy rate.

The introduction of a tactical command suite at Coxheath EOC had improved the deployment of critical care paramedics.

The EOC had appropriate measures to ensure service continuity in the event of a business continuity incident such as CAD failure.

The trust had recently purchased a new CAD system, which was due to go live at Coxheath EOC in July 2017.

The health and well-being of employees had improved with the introduction of protected meal breaks and staff finishing their shifts on time.

We found the trust had begun to engage with local safeguarding teams across Kent, Surrey and Sussex, and had started to roll out level three safeguarding children training to all registered clinical staff.

We saw assessments of patients followed the Joint Royal Colleges' Ambulance Liaison Committee (JRCALC) and Health and Care Professions Council (HCPC) standards. There were pathways for assessing and responding to the risk of deteriorating patients. This included trauma cases, suspected stroke and patients suffering from chest pain. We saw adult and paediatric patients treated correctly and referral pathways followed.

Effective:

National benchmarking data showed patient outcomes and response times were worse than most other English ambulance services. The trust’s call abandonment rates had worsened since our last inspection in 2016.

Appraisal rates were worse than the trust target and had worsened since our last inspection in 2016.

Most EOC policies in use at the time of our visit were outside their review date. Not all policies reflected current working practices or national guidance.

The trust failed to achieve national performance targets for the highest priority calls. Whilst this was similar to other ambulance trusts nationally, patients were put at risk through delays in treatment or taking them to hospital. The outcome data for the trust was worse than the national average for the majority of clinical outcomes measured.

Not all ambulance crews followed best practice guidelines and we observed poorly completed records and incomplete patient assessments.

However:

We saw improvements in multi-disciplinary working since our last inspection. The service had close links with local police and fire services.

The trust worked well with GPs, in community settings and the patient’s own home. Patients were supported to manage their own health by using non-emergency services such as their GP, local urgent care centres or alternative care pathways when it was appropriate to do so.

The trust’s call answering performance had improved since our last inspection in May 2016 although this was still worse than the AQI target of five seconds.

Trust wide guidance and training provided on the management of mental health patients were more in-depth and had been included in the key skills training programme. The process for assessing a patient’s capacity was more comprehensive than what was previously just a tick box exercise. This meant the assessment now considered the person’s ability to give consent to a specific act in a specific circumstance. This meant that the trust ensured persons providing care or treatment to service users had the competence and skills to do so safely.

Caring:

All EOC staff we met and observed consistently demonstrated compassion, kindness and respect towards callers and patients, including those in mental health crisis.

We observed examples of patients in distressing situations being supported by staff over the telephone. Staff displayed empathy and helped the patients cope emotionally, often by staying on the telephone until an ambulance crew arrived.

There were systems to support patients to manage their own health and to signpost them to alternative services where they could access more appropriate care and treatment, for example GP surgeries and walk-in centres.

Between May 2016 and April 2017 the trust’s Friends and Family Test performance was better than the England average in ten out of the 12 months.

We observed the majority of EUC staff treating patients with kindness and compassion. Staff and patients told us ambulance crews had delivered care and treatment above and beyond what was expected of them.

Responsive:

Complainants experienced lengthy delays waiting for a response to their complaint. There was limited evidence of learning from complaints to help improve services.

Dispatchers did not have access to information about the maximum weights that different vehicles could transport. This meant the EOC sometimes dispatched a vehicle that could not accommodate a patient’s relatives or escorts.

The three EOCs escalated to different levels of the demand management plan (DMP) independent of each other. This meant patients received a different response depending on which EOC answered their call at times of DMP at one EOC.

Access, flow and demand were some of the concerns from the 2016 inspection. ‘Immediate handovers’ have reduced the time some ambulance crews wait for handovers in some areas. However, the application of the immediate handover system was inconsistent. There were still significant problems with ambulance waiting times at hospitals across the South East.

Communication of changes to policies, particularly the policy about transporting bariatric patients, was inconsistent.

However:

Overall, the service made reasonable adjustments and took action to remove barriers to enable people to access services easily. These measures included an SMS emergency service system for people who were unable to talk on the telephone and a language line for people who did not speak English as a first language. However, there was inconsistent bariatric service provision and processes for accessing translation services were not always effective.

The service’s four-stage management plan for frequent callers was helping meet the individual needs of these patients.

When staff received training in areas such as end-of-life care, mental health and dementia, they reported that the training was valuable and they were able to apply it in their roles.

Well led:

The executive team did not have sufficient understanding of the scale and severity of the risk relating to call recording failure.

The culture of the EOC did not always encourage openness and candour.

Staff satisfaction was inconsistent, and morale at Banstead EOC was low.

We found insufficient or no progress with making improvements in the majority of the concerns for EUC reported in the previous May 2016 inspection, particularly around medicines management.

The trust’s governance processes remained inadequate. Whilst there had been changes to ensure improvements were made at a strategic level, monitoring of risks and quality in front line services had not always been implemented. Where it had been, practices had not been embedded. The trust could not fully provide adequate assurance of clinical and operational oversight.

Overall communication with staff was still poor, in particular changes of policies, processes and practices in areas such as medicines and transportation / vehicles. This meant the trust could not be fully assured that communication was effective and that practice was consistent across the trust.

Trust strategy and core values were not recognised by front line staff and staff did not feel engaged with the trust’s vision. Staff generally felt supported by their immediate managers but told us there remained a disconnection between front line staff and senior managers.

There were still no local risks identified and there was limited knowledge of the trust wide risk register.

There was some inconsistency in the way staff were treated with regard to accessing mandatory training and the implementation of the sickness absence management policy.

However:

We observed positive examples of local leadership from the operating unit managers (OUMs) at all three EOC. We saw that the EOC listened to staff and worked to address concerns raised in the local “Pulse” staff survey. All staff we spoke with felt supported and valued by their OUM.

We saw improvements in staff and public engagement since our last inspection. These included reward and recognition badges and the introduction of a patient experience group.

Staff were proud of the work they did and the support they and their colleagues offered one another. They felt positive about the organisation and that they were ‘heading in the right direction’.

There was a medicines improvement strategy and associated annual plan in development.

Managers had put a number of processes in place to deal with bullying and no longer tolerated it. In addition, staff felt bullying was a problem that was “dying out”.

We saw several areas of outstanding practice including:

We found the trust’s mental health street triage service to be an area of outstanding practice.

The Hazardous Area Response Team (HART) was an approved training centre of excellence and offered training to external agencies.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

The trust must take action to ensure they keep a complete and accurate recording of all 999 calls.

The trust must protect patients from the risks associated with the unsafe use and management of medicines in line with best practice and relevant medicines licences. This should include the appropriate administration, supply, security and storage of all medicines, appropriate use of patient group directions and the management of medical gas cylinders.

The trust must take action to ensure there are a sufficient number of clinicians in each EOC at all times in line with evidence-based guidelines.

The trust must take action to ensure all staff receive an annual appraisal in a timely way so that they can be supported with training, professional development and supervision.

The trust must take action to ensure all staff understand their responsibilities to report incidents.

The trust must ensure improvements are made on reporting of low harm and near miss incidents.

The trust must investigate incidents in a timely way and share learning with all relevant staff.

The trust must ensure all staff working with children, young people and/or their parents/carers, who could potentially contribute to assessing, planning, intervening and evaluating the needs of a child or young person and parenting capacity where there are safeguarding/child protection concerns, receive an appropriate level of safeguarding training.

The trust must ensure patient records are completed, accurate and fit for purpose, kept confidential and stored securely.

The trust must ensure the CAD system is effectively maintained.

The trust must ensure national performance targets are met.

The trust must improve outcomes for patients who receive care and treatment.

The trust must ensure the risk of infection prevention and control are adequately managed. This includes ensuring consistent standards of cleanliness in ambulance stations and vehicles, and hand hygiene practices and uniform procedure are followed.

The trust must ensure that governance systems are effective and fit for purpose. This includes systems to assess, monitor and improve the quality and safety of services.

The trust must ensure all medical equipment is adequately serviced and maintained.

The trust must continue to ensure there are adequate resources available to undertake regular audits and robust monitoring of the services provided.

The trust must ensure the systems and processes in place to manage, investigate and respond to complaints, and learn from complaints are robust.

In addition the trust should:

The trust should take action to audit 999 calls at a frequency that meets evidence-based guidelines.

The trust should ensure 100% of frequent callers have an Intelligence Based Information System (IBIS) or other personalised record to allow staff taking calls to meet their individual needs.

The trust should take action to ensure all patients with an IBIS record are immediately flagged to staff taking calls 24 hours a day, seven days a week.

The trust should consider reviewing the arrangements for escalation under the demand management plan (DMP) so that patients across the trust receive equal access to services at times of DMP.

The trust should consider how to improve communications about any changes to ensure that they are effective and timely, including the methods used.

The trust should review all out of date policies and standard operating procedures.

The trust should ensure all first aid bags have a consistent contents list and they are stored securely within the bags.

The trust should engage staff in the organisation’s strategy, vision and core values. This includes increasing the visibility and day to day involvement of the trust executive team and board, and the senior management level across all departments.

The trust should continue to sustain the action plan from the findings of staff surveys, including addressing the perceived culture of bullying and harassment.

The trust should continue to address the handover delays at acute hospitals.

The trust should ensure there are systems and resources available to monitor and assess the competency of staff.

The trust should ensure that patients are always involved in their care and treatment.

The trust should ensure that patients are always treated with dignity and respect.

The trust should ensure all ambulance stations and vehicles are kept secured.

The trust should ensure all vehicle crews have sufficient time to undertake daily vehicle checks within their allocated shifts.

The trust should ensure individual needs of patients and service users are met. This includes bariatric and service translation provisions for those who need access.

On the basis of this inspection, I have recommended the trust remains in special measures.

Professor Edward Baker

Chief Inspector of Hospitals

South East Coast Ambulance Service NHS Foundation Trust (SECAmb) is part of the National Health Service (NHS). The trust came into being on 1 July 2006, with the merger of the former Kent Ambulance Service, Surrey Ambulance Service and Sussex Ambulance Service. On 1 March 2011 SECAmb became a Foundation Trust. The trust employs over 3,660 staff working across 110 sites in Kent, Surrey and Sussex. This area covers 3,600 square miles which includes densely populated urban areas, sparsely populated rural areas and some of the busiest stretches of motorway in the country. It has a population of over 4.5 million people. There are 12 acute trusts within this area and 22 Care Commissioning Groups (CCGs).

The trust responds to 999 calls from the public and urgent calls from healthcare professional across Brighton and Hove, East Sussex, West Sussex, Kent and Medway, Surrey, and parts of North East Hampshire.It also provides NHS 111 services across the region and in Surrey provides non-emergency patient transport services (pre-booked patient journeys to and from healthcare facilities).

The emergency operations centre (EOC) receives and triages 999 calls from members of the public and other emergency services. It provides advice and dispatches ambulances as appropriate.The EOC also provides assessment and treatment advice to callers who do not need an ambulance response, a service known as “hear and treat”. Callers receive advice on how to care for themselves, or staff direct them to other services that could be of assistance.The EOC also manages requests from health care professionals to convey people either between hospitals or from community services into hospital.

The emergency operations centre received 929,822 emergency calls in 2014-15. The call volume had increased by 7.24% compared with the previous year.The trust had three emergency operations centres: Coxheath, Banstead and Lewes. The trust plans to move services from Banstead and Lewes EOCs to a new, purpose-built facility in Crawley in February 2017.

Patient Transport Services (PTS) for SECAmb provides a service for people who meet the eligibility criteria within Surrey and a small part of North East Hampshire. PTS headquarters is based in Dorking, Surrey and there are six bases across the area, located at or near the major hospitals. Figures provided show that PTS handles between 1800 and 1950 journeys per week and currently employs 126 staff.

We inspected this location as part of our planned comprehensive inspection programme. Our inspection took place on 3 to 6 May 2016. We looked at three core services: emergency operations centres, patient transport services and emergency and urgent care, including resilience and the hazardous area response team. The 111 service provided by the trust was inspected separately. During the inspection, we visited both ambulance premises and hospital locations in order to speak to patients and staff about the ambulance service.

Overall, we rated this service as inadequate. We rated emergency and urgent care as inadequate and the emergency operations centre and patient transport services as requires improvement.

Overall we rated the service as good for caring, requiresimprovement for effective and responsiveand inadequate for safe and well led.

Our key findings were as follows:

Are services safe?

The incident reporting culture, the processes for reporting and investigating incidents and the lack of learning from incidents did not support the safe provision of service.
Safeguarding arrangements within the trust were exceptionally weak. A lack of accountability, understanding and appropriate investigation was prevalent throughout the trust.
There was low attendance at infection control training leading to inconsistent hand hygiene practices.
The trust CAD system had not been appropriately updated.
The trust medicines management process had allowed staff to develop practice outside national guidance and best practice.
Low staffing levels were having an impact on both performance and fatigue of staff. The trust did not have access to information to review the mix of staff or safe staffing levels.

Are services effective?

The trust was not meeting national performance targets for response times.
The trust was benchmarked as the worst performing trust nationally for answering 999 calls within 5 seconds. Trust performance was as low as 95% within 80 seconds during March 2016.
Policies and procedures had not been updated in a timely manner or in line with national guidelines.
There was no tracking system for appraisals leading to inconsistencies in approach.
There was no competency framework in place against which to assess staff.
There was a lack of Mental Capacity Act training leading to a variable understanding within the trust.
There were protocols and guidance for pain relief and patients reported that pain relief had been offered and managed effectively.
The trust had well developed links with the police, fire brigade and GPs.

Are services caring?

Our observation of staff interacting with patients demonstrated patient empathy and focus.
We saw kindness and understanding from staff even when faced by volatile patients and members of the public.
We saw examples of staff providing patients, relatives and colleagues emotional support.
Call handlers in the 111 service communicated with callers in a non-judgemental way and treated patients as individuals.
Ambulance crews largely provided clear explanations to patients adopting a sensitive tone and posture during discussions.
PTS staff sensitively supported patients to find alternative modes of transport when they did not meet the criteria for accessing PTS.
There were processes to ensure that staff could access support following traumatic or difficult calls or attendances. Staff were observed providing immediate support to colleagues.

Are services responsive?

The processes for complaint response failed to meet expected targets. Complaints did not fully acknowledge organisational responsibility and there was little evidence of learning from complaints across the whole trust.
Organisational planning had not facilitated equal distribution of resources across the geographical area served.
A ‘tethering’ system resulted in some patients waiting longer than necessary for emergency attendances.
Handover delays at emergency departments often significantly exceeded the 15 minutes target and led to a major loss of productive ambulance capacity.
The trust was working closely with commissioners to plan services against the background of significant increases in demand.
The trust worked with strategic clinical networks, operational delivery networks and the trauma network to plan for complex care.

Are services well-led?

Roles and accountability within the executive team lacked clarity.
There was a lack of clarity regarding the respective roles of the three clinical directors within the executive team.
The board had numerous interim post holders and we saw evidence of inter-executive grievance.
Although there was a comprehensive clinical strategy, there was no form of measurement to monitor the attainment of the strategy pledges by the board.
Risk management was not structured in a way that allowed active identification and escalation to the board. Risks managed at board level did not have robust and monitored action plans.
Staff reported a culture of bullying and harassment.
The trust had actively sought to engage with the public, notably with the development of community first responders.
The trust was utilising social media in an attempt to inform and influence the use of trust services.
The trust had a positive culture of encouraging innovation, notably in the development of the paramedic workforce and the introduction of critical care and advanced paramedics.

We saw several areas of outstanding practice including:

The trust encouraged staff to take on additional roles and responsibilities and provided training and support to enhance the paramedic roles. The specialist paramedics’ roles such as the critical care paramedic had expanded and developed.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

take action to ensure all staff working with children, young people and/or their parents/carers and who could potentially contribute to assessing, planning, intervening and evaluating the needs of a child or young person and parenting capacity where there are safeguarding/child protection concerns receive an appropriate level of safeguarding training.
take action to ensure all Emergency Operations Centre premises containing confidential data and critical equipment are secure.
take action to ensure the CAD system is properly maintained.
take action to provide every operational Hazardous Area Response Team (HART) operative with no less than 37.5 hours protected training time every seven weeks.
formulate a contingency plan to mitigate the loss of the Patient Transport Services control room in Dorking that will allow the service to continue.
take action to ensure that governance systems are effective and fit for purpose. This includes systems to assess, monitor and improve the quality and safety of services.
take action to improve the reporting of low harm and near miss incidents.
take action to ensure that national performance targets are met.
take action to improve outcomes for patients who receive care and treatment.
take action to adequately manage the risk of infection prevention and control. This includes ensuring consistent standards of cleanliness in the ambulance stations, vehicles and staff hand hygiene practices.
take action to ensure there are always sufficient numbers of staff and managers to meet patient safety and operational standards requirements. This should include ensuring there are adequate resources for staff to usually take their meal breaks, finish on time, undertake administrative and training.
take action to recruit to the required level of HART paramedics in order to meet its requirements under the National Ambulance Resilience (NARU) specification.
ensure that ambulance crews qualifications, experience and capabilities are taken into account when allocating crews to ensure that patients are not put at risk from inexperienced and unqualified crews working together.
take action to protect patients from the risks associated with the unsafe use and management of medicines. This should include: appropriate use of patient group directives; the security and safe storage of both medicines and controlled drugs; the management of medical gas cylinders.
take action to ensure that patient records are completed appropriately, kept confidential and stored securely.

In addition the trust should:

take action to review all out-of-date policies and standard operating procedures.
develop procedures to ensure HART rapid response vehicles (RRVs) are relieved to attend HART incidents within the timescales set out in standards 08-11 of appendix three of the NHS service specification 2015-16: Hazardous area response teams.
take action to audit 999 calls at a frequency that meets evidence-based guidelines.
take action to put in place an effective and consistent process for feedback to be given to those who report incidents and develop a robust system for sharing lessons learned from incidents.
take action to ensure all staff receive an annual appraisal in a timely fashion in order that they can be supported with training, professional development and supervision.
take action to address discrepancies in the number of funded ambulance hours with activity across the trust.
ensure all first aid bags have a consistent list of contents, stored securely within the bags.
devise a system that will accurately track the whereabouts of the PTS defibrillators.
include a question regarding the patient’s DNACPR status at the point of each transport booking.
provide Mental Capacity Act and Deprivation of Liberty Safeguards training to all operational staff.
take action to engage staff in the organisations strategy, vision and core values.This includes increasing the visibility and day to day involvement of the trust executive team and board across all departments.
develop a detailed and sustained action plan to address the findings of the staff survey including addressing the perceived culture of bullying and harassment.
continue to take action to address the handover delays at the acute hospitals.
ensure there are adequate resources available to undertake regular audits and robust monitoring of the services it provided.
ensure that there is adequate access to computers at ambulance stations to facilitate e-learning, incident reporting and learning from incidents.
ensure there is a robust system in place to manage, investigate and respond and learn from complaints.This includes ensuring that all staff understand the Duty of Candour and their responsibilities under it.
ensure that there is appropriate trust wide guidance and training provided regarding attending patients with mental health problems. This should include reviewing the current arrangements for assessing capacity and consent.
ensure that there are structured plans in place for all frequent callers as per national guidance. The information regarding this should be collected and monitored as per national guidelines.
ensure that there are systems and resources available to monitor and assess the competency of staff. This includes ensuring they always involve patients in the care and treatment and treat them with dignity and respect.
ensure there are robust systems in place to ensure all medical equipment is adequately serviced and maintained.
ensure that vehicles and ambulance stations are kept secure.
ensure that there is sufficient time for vehicle crews to undertake their daily vehicle checks within their allocated shift pattern.

South East Coast Ambulance Service NHS Foundation Trust

All Inspections

26 July to 2 August 2022

During an inspection of Emergency and urgent care

26 July to 2 August 2022

During a routine inspection

How we carried out the inspection

What we found

Our inspection team

26 July to 2 August 2022

During an inspection of Resilience

22 February

During a routine inspection

22 February

During an inspection of Emergency operations centre (EOC)

22 February

During an inspection of Emergency and urgent care

4 June to 10 July 2019

During a routine inspection

4 June to 10 July 2019

During an inspection of Emergency and urgent care

4 June to 10 July 2019

During an inspection of Emergency operations centre (EOC)

18th to 20th July 2018

During a routine inspection

18th to 20th July 2018

During an inspection of Emergency and urgent care

18th to 20th July 2018

During an inspection of Emergency operations centre (EOC)

18th to 20th July 2018

During an inspection of Resilience

15-18 May 2017

During a routine inspection

Professor Edward Baker

03-06 May 2016

During a routine inspection

Professor Sir Mike Richards

Chief Inspector of Hospitals